IBD Presented by- Dr. Mohammad Rehan DNB Medicine SDMH Jaipur Moderator- Dr. Madhulika Sharma HOD (General Medicine)

1. Dr. Mohammad Rehan

2. • It includes a group of chronic disorders that cause
inflammation or ulceration in large and small intestines.
• 2 major types: Ulcerative colitis (UC) and Crohn’s disease
(CD)
INCIDENCE-
 Highest incidence in Europe, the United Kingdom, and North
America.
 Urban areas > rural areas.
 high socioeconomic classes > lower socioeconomic classes.
INFLAMMATORY BOWEL DISEASE

3. • Recently two studies, both from northern India,
reported a population prevalence of ulcerative colitis
(UC) of approximately 42 per 100,000 .
• No such population based study is available for
crohn’s disease.

4. EPIDEMIOLOGY

5. ETIOPATHOGENESIS
 Exact cause is
unknown.
• Genetic factors
• Immunological factors
• Microbial factors
• Psychosocial factors

7. GENETIC FACTORS
• Ulcerative colitis is more common in DR2-related genes.
• Crohn’s disease is more common is DR5 DQ1 alleles.
• 3-20 times higher incidence in first degree relatives.

8. IMMUNOLOGIC FACTORS
• Defective regulation of immunosuppression.
• Activated CD+4 cells activate other inflammatory cells
like macrophages & B-cells or recruit more inflammatory
cells by stimulation of homing receptor on leucocytes &
vascular epithelium resulting in inflammation of mucosa
and sub mucosa.

11. PATHOGENESIS OF IBD
American Gastroenterological Association Institute, Bethesda,
MD. Sartor RB. Nat Clin Pract Gastroenterol Hepatol. 2006;3:390-
407.
Normal
Gut
Tolerance-
controlled
inflammation
(Infection, NSAID, other)
Complete Healing
Chronic Inflammation
Genetically
Susceptible
Host
Acute Inflammation
↓ Immunoregulation, failure of
repair or bacterial clearance
Acute injury
Environmental
triggers

12. PATHOLOGY
Macrocopic features
•Ulcerative colitis
 Usually involves rectum & extends proximally to involve all
or part of colon.
 Spread is in continuity.
 About 40–50% of patients have disease limited to the rectum and
rectosigmoid.
 30–40% have disease extending beyond the sigmoid but not
involving the whole colon, and
 20% have a total colitis (10–20% patients have backwash ilietis).

14.  Mild disease- erythematous & sand paper appearance
(fine granular surface) of mucosa.
 Moderate-marked erythema, coarse granularity, contact
bleeding & no ulceration.
 Severe- spontaneous bleeding, edematous & ulcerated
(collar button ulcer) mucosal surface.
 Long standing-epithelial regeneration so pseudopolyps ,
mucosal atrophy & disorientation leads to a
precancerous condition.
 Eventually can lead to shortening and narrowing of
colon.
 Fulminant disease-Toxic colitis/ megacolon/ perforation

15. ULCERATIVE
COLITIS
Ulcer
Pseudopolyps

16. MICROSCOPIC FEATURES
 Limited to mucosa & sub mucosa
 Crypts atrophy & irregularity
 Superficial erosion
 Diffuse mixed inflammation
 Basal lymphoplasmacytosis

17. Crypt
distortion
Diffuse
inflammation

19. MACROSCOPIC FEATURES
• Crohn’s disease
Can affect any part of GIT.
Transmural involvement.
Segmental with skip lesions.
Cobblestone appearance of mucosa.
Creeping fat- adhesions & fistula.

22. MICROSCOPIC
FEATURES
• Aphthous ulcerations.
• Focal crypt abscesses.
• Granuloma formation- pathognomic.
• Submucosal or subserosal lymphoid
aggregates.
• Transmural involvement with fissure
formation.

25. CLINICAL FEATURES
• Ulcerative colitis
Diarrhea
Rectal bleeding
Tenesmus
Passage of mucus
Crampy abdominal pain
 Systemic symptoms fever, weight loss
 Extra intestinal manifestations

26. • Physical signs
Proctitis – Tender anal canal & blood on rectal
examination.
Extensive disease-tenderness on palpation of
colon.
Toxic colitis-severe pain &bleeding.
If perforation-signs of peritonitis.

27. 1. Truelove SC, et al. Br Med J. 1955;2:1041-1045.
2. Sandborn WJ. Curr Treat Options Gastroenterol.1999;2:113-118.
CLINICAL SEVERITY OF UC
Mild Moderate Severe Fulminant
Bowel movement <4/day Intermediate >6 >10
Blood in stool Intermittent moderate Frequent Continuous
Temperature Normal <37.5° >37.5° >37.5°
Pulse Normal <90bpm >90 bpm >90 bpm
Hemoglobin Normal >75% <75% Transfusion
required
ESR <30 mm/hour >30 mm/hour >30 mm/hour
Clinical signs Abdominal
tenderness
Abdominal
distension and
tenderness

28. EXTRA INTESTINAL MANIFESTATIONS OF
ULCERATIVE COLITIS

29. DIAGNOSIS
• Laboratory tests
• Endoscopy
• Radiography
• Tissue Biopsy

30. LABORATORY TESTS
• Hemogram
 ESR is increased
 Platelet count-increased
 Hemoglobin-decreased
• C-reactive protein is increased
• Fecal Calprotectin levels correlate with histological
inflammation, predict relapses & detect pouchitis.
• Fecal lactoferrin- high levels indicate intestinal
inflammation.

31. BARIUM ENEMA

32. BARIUM ENEMA
• Fine mucosal granularity-
earliest radiological change.
• Superficial ulcers seen
• Collar button ulcers- s/o
mucosal penetration
• Pipe stem appearance- loss of
haustrations
• Narrow & short colon-
• Ribbon contour colon

33. SIGMOIDOSCOPY
• Always abnormal
• Loss of vascular patterns
• Granularity
• Friability
• Ulceration

34. Colonoscopy with acute ulcerative colitis: severe
colon inflammation with erythema, friability, and
exudates.

36. CLINICAL FEATURES
ILEAL CROHN’S DISEASE
 Abdominal pain
 Diarrhea
 Weight loss
 Low grade fever
JEJUNOILEITIS - associated with a loss of digestive
and absorptive surface, resulting in
 Malabsorption
 Steatorrhea

37. Colitis and perianal disease
• Bloody diarrohea
• Passage of mucus
• Lethargy
• Malaise
• Anorexia
• Weight loss
Contd. Clinical features

38. GASTRODUODENAL DISEASE –
• Symptoms and signs of upper GI tract disease include
nausea, vomiting, and epigastric pain.
• The second portion of the duodenum is more commonly
involved than the bulb.
• Patients with advanced gastro duodenal CD may develop a
chronic gastric outlet obstruction.

39. DIAGNOSIS
• Laboratory tests
• Endoscopy
• Radiography
• Biopsy
• CT enterography

40. LABORATORY TESTS
• Anemia
• Leukocytosis
• ESR-elevated
• CRP-elevated
• Hypoalbuminemia

41. BARIUM ENEMA
String sign
Represents long areas of
circumferential inflammation and
fibrosis, resulting in long segments
of luminal narrowing.

42. COLONOSCOPY

43. • Endoscopic features of CD include rectal sparing,
aphthous ulcerations, fistulas, and skip lesions.
• Colonoscopy allows examination and biopsy of
mass lesions or strictures and biopsy of the
terminal ileum.
• Upper endoscopy is useful in diagnosing
gastroduodenal involvement in patients with
upper tract symptoms

45. CT- ENTEROGRAPHY
• Mural hyper
enhancement.
• Stratification.
• Engorged vasa recta.
• Perienteric inflammatory
changes.

48. TREATMENT
LIFE STYLE CHANGES
DIET CHANGE
DRUGS
SURGERY

49. DIETARY
CHANGES
 Eating :
 Low-fat foods.
 Smaller, more
frequent meals.
 Avoiding :
 foods high in
undigestible fiber.
 Refined sugars .

50. LIFESTYLE CHANGES
NO SMOKING
REDUCING STRESSDOING EXERCISE
TAKING REST

51. Therapeutic approach for IBD

52. DRUGS
• 5-ASA agents
• Glucocorticoids
• Antibiotics
• Immunosuppresants
• Biological therapy

53. 5-ASA AGENTS
• Sulfasalazine – combination of 5-aminosalicylic acid( anti
inflammatory ) + sulfapyradine-antibacterial).
 Partially absorbed in jejunum but remainder passes in colon
 Therapeutic action –inhibition of P.G.s & leukotriene
synthesis, free radical scavanging, free radical scavanging,
impairement of white cell adhesion and function, inhibition
of cytokine synthesis.
• Mesalamine group (coating 5-ASA with acrylic resins), e.g.
Asacol, Pentasa, Balsalazide (prodrug of 5-ASA).
• Olsalazine (5-ASA dimer cleaves in colon).

55. Distribution of 5-ASA Preparations
Oral
•Varies by agent: may be released in the
• distal/terminal ileum, or colon1
Suppositories
• Reach the upper rectum2,5
• (15-20 cm beyond the anal verge)
Liquid Enemas
• -May reach the splenic flexure2-4
• -Do not frequently concentrate in the
rectum3
Topical Action of 5-ASA: Extent of Disease
Impacts Formulation Choice
1. Sandborn WJ, et al. Aliment Pharmacol Ther. 2003;17:29-42; 2. Regueiro M, et al. Inflamm Bowel Dis. 2006;12:972–978; 3. Van Bodegraven AA,
et al. Aliment Pharmacol Ther. 1996; 10:327-332; 4. Chapman NJ, et al. Mayo Clin Proc. 1992;62:245-248; 5. Williams CN, et al. Dig Dis Sci. 1987;32:71S-75S.

56.  Use
• Mainstay of OPD treatment for mild to moderate active
UC & Crohns colitis.
• Maintaining remission
• May reduce risk of colorectal cancer
 Adverse effects
• Nausea, headache, epigastric pain, diarrhoea,
hypersensitivity, pancreatitis
• Caution in renal impairment, pregnancy, breast feeding

57. GLUCOCORTICOIDS
• Anti inflammatory agents for moderate to severe
relapses (including IV treatment; enemas for
acute proctitis)
• Inhibition of inflammatory pathways.
• No role in maintenance therapy
• Prednisone-40-60mg/day
• Budesonide- 9mg/dl used for 2-3 months & then
tapered.

58. ANTIBIOTICS
• Metronidazole is effective in active inflammatory,
fistulous & perianal Crohn’s Disease.
 Dose-15-20mg/kg/day in 3 divided doses.
• Ciprofloxacin 500mg BD.
• Rifaximin.
• No role of antibiotics in active/quiescent UC.

59. IMMUNOSUPPRESANTS
• Thiopurines- Azathioprine, 6-mercaptopurine.
• Methotrexate
• Cyclosporine
 Reduce inflammation by suppressing immune system’s
response (which might damage digestive tissue) invading
virus or bacterium.
• Used in patients unresponsive to steroid &
amino salicylates

60. CYCLOSPORINE
 Preventing clonal expansion of T cell subsets.
Use
• Steroid sparing
• Active and chronic disease
Side effects
 Minor: tremor, paresthesias, malaise, headache
gingival hyperplasia, hirsutism.
 Major: renal impairment, infections, neurotoxicity

61. BIOLOGICAL THERAPY
Infliximab
 Anti TNF monoclonal antibody.
 Binds to TNF trimers with high affinity, preventing cytokine from
binding to its receptors.
 It also binds to membrane-bound TNF- a and neutralizes its activity
& also reduces serum TNF levels.
• Use
• Fistulizing CD
• Severe active CD
• Refractory/intolerant of steroids or immunosuppression
• Side effects
• Infusion reactions
• Sepsis
• Reactivation of Tuberculosis
• Increased risk of Tuberculosis

62. • Newer Biologics
1) Adalimumab
2) Certolizumab
3) Golimumab

63. OTHER MEDICATIONS
 Anti- diarrheal - Loperamide
(Imodium)
 Laxatives - senna, bisacodyl
 Pain relievers- acetaminophen
(Tylenol).
 Iron supplements

64. SURGERY
Ulcerative colitis
Indications:
• Fulminating disease.
• Chronic disease with anemia, frequent stools,
urgency & tenesmus.
• Steroid dependent disease.
• Risk of neoplastic change.
• Extra intestinal manifestations.
• Severe hemorrhage or stenosis.

65. • Reconstructive Proctocolectomy with ileoanal
pouch.
• Proctocolectomy & ileostomy.
• Rectal & anal dissection.
• Colectomy with ileorectal anastomosis.
• Ileostomy with intra abdominal pouch.
Surgery in ulcerative colitis

66. OTHERS
• Proctocolectomy & ileostomy.
• Rectal & anal dissection.
• Colectomy with ileorectal anastomosis.
• Ileostomy with intra abdominal pouch.

67. SURGERY IN CROHN’S
DISEASE
• Ileocaecal resection.
• Segmental resection.
• Colectomy & ileorectal anastamosis.
• Temporary loop ileostomy.
• Proctocolectomy.
• Strictureplasty.

70. DIFFERENTIAL DIAGNOSIS OF UC AND CD